Allocation aux adultes handicapés : pathologies et recours aux soins des bénéficiaires en 2017.

OBJECTIVE: We described the pathologies and health care utilization of beneficiaries of the general health insurance scheme via the Allocation Adulte Handicapé (AAH - Adult Disability Allowance) compared to the general population. METHOD: Mapping of pathologies and expenditures allowed the identification of 58 pathologies and chronic treatments in the SNDS, thanks to ICD-10 codes for long-term conditions or hospitalizations, specific drugs or medical procedures, among all beneficiaries of the general health insurance scheme aged 20 to 64 years with reimbursed care (>1€) in 2017. The prevalence and annual rates of care utilization among all beneficiaries of the general scheme via AAH (“AAH” group) and in the rest of the population (“non-AAH”) were standardized and described. RESULTS: Among the 793,934 (2.51% of the population) “AAH” persons, all the pathologies studied were more frequent than among the “non-AAH”, with 44% having psychiatric pathologies (compared with 3.2%), and 14% a neurological pathology (compared with 1%). AAH beneficiaries were more likely to use hospital care (63% versus 40%), but less likely to use specialist care (63% versus 68%) and dental care (37% versus 45%). CONCLUSION: The beneficiaries of the general scheme via the AAH had mainly psychiatric and neurological pathologies, but other pathologies were also much more frequent than in the general population. The lower use of dental and specialist care was probably related to a lack of access to care, potentially caused by the absence of 100% coverage of care.

The Economic Burden of Disease in France From the National Health Insurance Perspective: The Healthcare Expenditures and Conditions Mapping Used to Prepare the French Social Security Funding Act and the Public Health Act.

BACKGROUND: Identifying the most frequently treated and the costliest health conditions is essential for prioritizing actions to improve the resilience of health systems. OBJECTIVES: Healthcare Expenditures and Conditions Mapping describes the annual economic burden of 58 health conditions to prepare the French Social Security Funding Act and the Public Health Act. DESIGN: Annual cross-sectional study (2015-2019) based on the French national health database. SUBJECTS: National health insurance beneficiaries (97% of the French residents). MEASURES: All individual health care expenditures reimbursed by the national health insurance were attributed to 58 health conditions (treated diseases, chronic treatments, and episodes of care) identified by using algorithms based on available medical information (diagnosis coded during hospital stays, long-term diseases, and specific drugs). RESULTS: In 2019, €167.0 billion were reimbursed to 66.3 million people (52% women, median age: 42 y). The most prevalent treated diseases were diabetes (6.0%), chronic respiratory diseases (5.5%), and coronary diseases (3.2%). Coronary diseases accounted for 4.6% of expenditures, neurotic and mood disorders 3.7%, psychotic disorders 2.8%, and breast cancer 2.1%. Between 2015 and 2019, the expenditures increased primarily for diabetes (+€906 million) and neurotic and mood disorders (+€861 million) due to the growing number of patients. "Active lung cancer" (+€797 million) represented the highest relative increase (+54%) due to expenditures for the expensive drugs and medical devices delivered at hospital. CONCLUSIONS: These results have provided policy-makers, evaluators, and public health specialists with key insights into identifying health priorities and a better understanding of trends in health care expenditures in France.

Defining a risk-adjustment formula for the introduction of population-based payments for primary care in France.

Novel risk-adjusted payment models for financing primary care are currently being experimented in France. In particular, pilot schemes including shared-savings contracts or prospectively allocated capitation payments are implemented for voluntary primary care structures. Such payment mechanisms require defining a risk-adjustment formula to accurately estimate expected expenditure while maintaining appropriate efficiency incentives. We used nationwide data from the French national health data system (SNDS) to compare the performance of different prospective models for total and outpatient expenditure prediction among more than 8 million individuals aged 65 or more and their application at an aggregate level. We focused on the characterization of morbidity status and on the contextual characteristics to include in the formula. We proposed a set of practical routinely available predictors with fair performance for patient-level expenditure prediction (explaining 32% of variance) that could be used to risk-adjust prospective payments in the French setting. Morbidity information was the strongest predictor but could lead to considerable error in predicted expenditures if introduced as independent binary variables in multiplicative models, underlining the importance of summary morbidity measures and of using the appropriate metric to assess model performance. Distribution of aggregate-level allocations was greatly modified according to the method to account for contextual characteristics. Our work informs the introduction of risk-adjusted models in France and underlines efficiency and fairness issues raised.

Evolution of health care utilization and expenditure during the year before death in 2015 among people with cancer: French snds-based cohort study.

BACKGROUND: Cancer patients have one of the highest health care expenditures (HCE) at the end of life. However, the growth of HCE at the end of life remains poorly documented in the literature. OBJECTIVE: To describe monthly reimbursed expenditure during the last year of life among cancer patients, by performing detailed analysis according to type of expenditure and the person's age. METHOD: Data were derived from the Système national des données en santé (SNDS) [national health data system], which comprises information on ambulatory and hospital care. Analyses focused on general scheme beneficiaries (77% of the French population) treated for cancer who died in 2015. RESULTS: Average reimbursed expenditure during the last year of life was €34,300 per person in 2015, including €21,100 (62%) for hospital expenditure. "Short-stays hospital" and "rehabilitation units" stays expenditure were €14,700 and €2000, respectively. Monthly expenditure increased regularly towards the end of life, increasing from 12 months before death €2000 to €5200 1 month before death. The highest levels of expenditure did not concern the oldest people, as average reimbursed expenditure was €50,300 for people 18-59 years versus €25,600 for people 80-90 years. Out-of-pocket payments varied only slightly according to age, but increased towards the end of life. CONCLUSION: A marked growth of HCE was observed during the last 4 months of life, mainly driven by hospital expenditure, with a more marked growth for younger people.

Age, Male Gender, and Social Deprivation Are Associated with a Lower Rate of Insulin Pump Therapy Initiation in Adults with Type 1 Diabetes: A Population-Based Study.

Objectives: The objective of this population-based study was to identify factors associated with insulin pump therapy initiation in adults with insulin-requiring diabetes in France in 2015. Method: People with insulin-requiring diabetes and their characteristics were identified from the national health data system. Factors associated with insulin pump therapy initiation were identified by logistic regression analysis. Results: The study focused on 614,913 adults with diabetes treated by multiple daily injections before 2015: 4083 of them initiated insulin pump therapy during the year (71% of them had type 1 diabetes, T1D). Factors associated with insulin pump therapy initiation were the number of consultations with an endocrinologist within the past 2 years (2 vs. 0, odds ratio [OR] = 1.5, P < 0.01), the presence of a chronic cardiovascular or neurovascular disease (OR = 1.6 for T1D, OR = 1.3 for type 2 diabetes [T2D], P < 0.01) and treatment with antidepressants/anxiolytics (OR = 1.2 for T1D, OR = 1.4 for T2D, P < 0.01). The other determinants were female gender (OR = 1.5, P < 0.01) and history of hospitalization for acute metabolic complications (OR = 1.14, P < 0.01) in T1D. Factors associated with less insulin pump therapy initiation were age, duration of diabetes, end-stage renal disease, and social deprivation (OR = 0.662, P < 0.01, T1D only). Conclusion: Predictive factors of insulin pump therapy initiation in people with insulin-requiring diabetes in 2015 in France were globally consistent with clinical practice guidelines. Age, male gender, and social deprivation are still associated with a lower rate of insulin pump therapy initiation in adults with T1D.

French annual national observational study of 2015 outpatient and inpatient healthcare utilization by approximately half a million patients with previous heart failure diagnosis.

BACKGROUND: Heart failure management guidelines have been published, but the degree of adherence to these guidelines remains unknown. AIMS: To study in 2015 healthcare utilization and causes of death for people previously identified with heart failure. METHODS: The national health data system was used to identify adult general scheme (86% of the French population) hospitalized for heart failure between 2011 and 2014 or with only a long-term chronic disease allowance for heart failure. The frequency and median (interquartile range) of at least one healthcare use among those still alive in 2015 was calculated. RESULTS: A total of 499,296 adults (1.4% of the population) were included, and 429,853 were alive in 2015; median age 79 (68-86) years. At least one utilization was observed for a general practitioner in 95% of patients (median 8 [interquartile range 5-13] consultations), a cardiologist in 42% (2 [1-3]), a nurse in 78% (16 [4-100]), a loop diuretic in 64% (11 [8-12] dispensations), an aldosterone antagonist in 21% (8 [5-11]), a thiazide in 15% (7 [4-11]), a renin-angiotensin system inhibitor in 68% (11 [8-13]), a beta-blocker in 65% (11 [7-13]), a beta-blocker plus a renin-angiotensin system inhibitor in 57%, and a beta-blocker plus a renin-angiotensin system inhibitor plus an aldosterone antagonist in 37%. Hospitalization for heart failure was present for 8% (1 [1,2]). Higher levels of healthcare utilization were observed in the presence of hospitalization for heart failure before 2015. Among the 13.9% of people who died in 2015, heart failure accounted for 8% of causes, cardiovascular disease accounted for 39%. CONCLUSIONS: General practitioners and nurses are the main actors in the regular follow-up of patients with heart failure, whereas cardiologist consultations and dispensing of first-line treatments are insufficient with respect to guidelines.

Patient stratification for risk of readmission due to heart failure by using nationwide administrative data.

BACKGROUND: Identifying patients with heart failure (HF) who are most at risk of readmission permits targeting adapted interventions. The use of administrative data enables regulators to support the implementation of such interventions. METHODS AND RESULTS: In a French nationwide cohort of patients aged 65 years or older, surviving an index hospitalization for HF in 2015 (N = 70,657), we studied HF readmission predictors available in administrative data, distinguishing HF severity from overall morbidity and taking into account the competing mortality risk, over a 1-year follow-up period. We also computed cumulative incidences and daily rates of HF readmission for patient groups defined according to HF severity and overall morbidity. Of the patients, 31.8% (n = 22,475) were readmitted at least once for HF, and 17.6% (n = 12,416) died without any readmission for HF. HF severity and overall morbidity were the strongest readmission predictors were the strongest readmission predictors (subdistribution hazard ratios 2.66 [95% CI: 2.52-2.81] and 1.37 [1.30-1.45], respectively, when comparing extreme categories). Overall morbidity and age were more strongly associated with the rate of death without HF readmission (cause-specific hazard ratios). The difference in observed HF readmission between patient risk groups was approximately 40% (21.9%, n = 2144/9,786 vs 60.4%, n = 618/1023). CONCLUSIONS: Segmentation of HF patients into readmission risk groups is possible by using administrative data, and it enables the targeting of preventive interventions.

Intensity of Care, Expenditure, and Place of Death in French Women in the Year Before Their Death From Breast Cancer: A Population-Based Study.

Health care utilization of women with breast cancer (BC) during the last year of life, together with the causes and place of death and associated expenditure have been poorly described. Women treated for BC (2014-2015) with BC as a cause of death in 2015 and covered by the national health insurance general scheme (77% of the population) were identified in the French health data system (n = 6,696, mean age: 68.7 years, SD ± 15). Almost 70% died in short-stay hospitals (SSH), 4% in hospital-at-home (HaH), 9% in Rehab, 5% in skilled nursing homes (SNH) and 12% at home. One-third presented cardiovascular comorbidity. During the last year, 90% were hospitalized at least once in SSH, 25% in Rehab, 13% in HaH and 71% received hospital palliative care (HPC), but only 5% prior to their end-of-life stay. During the last month, 85% of women were admitted at least once to a SSH, 42% via the emergency department, 10% to an ICU, 24% received inpatient chemotherapy and 18% received outpatient chemotherapy. Among the 83% of women who died in hospital, independent factors for HPC use were cardiovascular comorbidity (adjusted odds ratio, aOR: 0.83; 95%CI: 0.72-0.95) and, in the 30 days before death, at least one SNH stay (aOR: 0.52; 95%CI: 0.36-0.76), ICU stay (aOR: 0.36; 95%CI: 0.30-0.43), inpatient chemotherapy (aOR: 0.55; 95%CI: 0.48-0.63), outpatient chemotherapy (aOR: 0.60; 95%CI: 0.51-0.70), death in Rehab (aOR: 1.4; 95%CI: 1.05-1.86) or HAH (aOR: 4.5; 95%CI: 2.47-8.1) vs SSH. Overall mean expenditure reimbursed per woman was €38,734 and €42,209 for those with PC. Women with inpatient or outpatient chemotherapy during the last month had lower rates of HPC, suggesting declining use of HPC before death. This study also indicates SSH-centered management with increased use of HPC in HaH and Rehab units and decreased access to HPC in SNH.

Outpatient healthcare utilization 30 days before and after hospitalization for heart failure in France: Contribution of the national healthcare database (Systèmenationaldesdonnéesdesanté).

BACKGROUND: Guidelines have been published concerning patient management after hospitalization for heart failure. The French national healthcare database (Systèmenationaldesdonnéesdesanté; SNDS) can be used to compare these guidelines with real-life practice. AIMS: To study healthcare utilization 30 days before and after hospitalization for heart failure, and the variations induced by the exclusion of institutionalized patients, who are less exposed to outpatient healthcare utilization. METHODS: We identified the first hospitalization for heart failure in 2015 of adult beneficiaries of the health insurance schemes covering 88% of the French population, who were alive 30 days after hospitalization. Outpatient healthcare utilization rates during the 30 days after hospitalization and the median times to outpatient care, together with their interquartile ranges, were described for all patients, and for a subgroup excluding institutionalized patients. RESULTS: Among the 104,984 patients included (mean age 79 years; 52% women), 74% were non-institutionalized (mean age 78 years; 47% women). The frequencies of at least one consultation after hospitalization and the median times to consultation were 69% (total sample) vs. 78% (subgroup excluding institutionalized patients) and 8 days (interquartile range 3; 16) vs. 7 days (3; 15) for general practitioners, 20% vs. 21% and 14 days (7; 23) vs. 16 days (9; 24) for cardiologists and 58% vs. 69% and 3 days (1; 9) vs. 2 days (1; 7) for nurses, with reimbursement of diuretics in 77% vs. 86%, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers in 48% vs. 55% and beta-blockers in 55% vs. 63%. Departmental variations, excluding institutionalized patients, were large: general practice consultations (interquartile range 74%; 83%), cardiology consultations (11%; 23%) and nursing care (68%; 77%). CONCLUSIONS: Low outpatient healthcare utilization rates, long intervals to first healthcare utilization and departmental variations indicate a mismatch between guidelines and real-life practice, which is accentuated when including institutionalized patients.

Intensity of care, expenditure, place and cause of death people with lung cancer in the year before their death: A French population based study.

INTRODUCTION: Health care utilization of people with lung cancer (LC) the last year of life, their causes of death and place of death and the associated expenditure have been poorly described together. Then we conducted an observational study. METHODS: People with LC covered by the French health Insurance general scheme (77% of the population) who died in 2015 were identified in the national health data system, together with their health care utilization and, in 95% of cases, their causes of death. RESULTS: A total of 22,899 individuals were included (mean age: 68 years, SD±11.4), 72% of whom died in short-stay hospitals (SSH), 4% in hospital-at-home, 8% in Rehab hospital, 2% in skilled nursing homes and 14% at home. One-half of these people had also a chronic respiratory tract disease and 18% another cancer. Hospital palliative care (HPC) was identified for 65% of people, but for only 9% prior to their end-of-life stay. During the last month of life, 49% of people had two or more SSH stays, 15% were admitted to an intensive care unit, 23% received a chemotherapy session (13% during the last 14 days). The main cause of death was cancer for 92% of individuals (LC for 82%) The mean expenditure during the last year of life was €43,329 per individual. DISCUSSION: This study indicates high rates of intensive care unit admissions and chemotherapy during the last month of life and a SSH hospital-centered management with intensive use of HPC mainly during the end-of-life stay.

Cancer and end of life: the management provided during the year and the month preceding death in 2015 and causes of death in France.

PURPOSE: The management of cancer patients at the end of life in France and their causes of death are not well known. METHODS: People managed for cancer in 2014-2015, who died in 2015 and who were covered by the national health insurance general scheme (77% of the French population) were selected from the national health data system in order to analyze the health care reimbursed during the year and the month before their death. RESULTS: This study included 125,497 people (mean age 73 years, SD 12.5) managed for cancer: colorectal: 12%, lung: 18%, prostate: 9%, breast: 8% and other: 62%. Almost 67% of people died in short-stay hospitals (SSH), 8% died in rehabilitation units (Rehab), 4% died in hospital at home (HaH), 5% died in skilled nursing homes (SNH) and 15% died at home or another place. The mean annual duration of all types of hospitalization was 70 days (SD 66) and 59% of patients had received hospital palliative care (HPC). During the last month of life, 42% of people had attended an emergency department at least once and people who had received HPC were less often admitted to an intensive care unit (10% versus 23%, 15% overall). During the month before death, 17% of patients had received intravenous chemotherapy (lung 23%, breast 21%) and 9% had received a pharmacy reimbursement for another form of chemotherapy (prostate 24%, breast 19%). The main cause of death was a tumour for 81% of patients: after management of lung cancer in 91% of cases, breast cancer in 81% of cases, colorectal cancer in 76% of cases and prostate cancer in 63% of cases. CONCLUSIONS: Cancer management and death mostly occurred in SSH in France. Cancer patients frequently attend the emergency department and frequently receive chemotherapy during the last month of life. These data continue to contrast with those observed in Scandinavian- and English-speaking countries, in which management of the end of life at home is preferred.

Intensity of care for cancer patients treated mainly at home during the month before their death: An observational study.

BACKGROUND: Little is known regarding healthcare for cancer patients treated mainly at home during the month before they die. The aim of this study was to provide information on how they were treated and what were their causes of death. METHODS: This population-based observational study analysing information obtained from the French national healthcare data system (SNDS) included adult health insurance beneficiaries treated for cancer who died in 2015 after having spent at least 25 of their last 30 days at home. RESULTS: Among the cancer patients who died in 2015, 25,463 (20%) were included [mean age (±SD) 74±13.2 years, men 62%]; 54% of them died at home. They were slightly older (75 vs. 73 years) than those who died in hospital, had less frequently received hospital palliative care during the year preceding their deaths (19% vs. 41%) and had less often used medical transport (41% vs. 73%) to an emergency department (8% vs. 62%), to hospital-based (11% vs. 17%) or community-based (16% vs. 12%) chemotherapy, to a general practitioner (73% vs. 78%) or to a community-based nursing service (63% vs. 73%). However, when they consulted a general practitioner (median 3 visits vs. 2) or a nurse (median 22 nursing procedures vs. 10) during their last month of life, visits were more frequent. The leading cause of death was tumour, which represented 69% of deaths at home vs. 74% of deaths in hospital. CONCLUSIONS: In France, home management during the last month of life is uncommon and even when it is occurs, in one out of two cases patients pass away in a hospital setting. This study is an interrogation on medical choices, given the wish of many of the French to die at home and placing their choices in an international perspective.

Management and intensity of medical end-of-life care in people with colorectal cancer during the year before their death in 2015: A French national observational study.

The care pathway of patients with colorectal cancer (CRC) 1 year prior to death, their causes of death and the healthcare use, and associated expenditure remain poorly described together. People managed for CRC (2014-2015), covered by the national health insurance general scheme and who died in 2015 were selected from the national health data system. A total of 15 361 individuals (mean age: 75 years, SD: 12.5 years) were included, almost 66% of whom died in short-stay hospital (SSH), 9% in hospital at home (HaH), 4% in rehabilitation units (Rehab), 6% in skilled nursing homes (SNH), and 15% at home. At least one other cancer was identified for one-third of these people. Almost one-half of people presented cardiovascular comorbidity, 21% had chronic respiratory disease, and 13% had a neurological or degenerative disease. During the last month of life, 83% were admitted at least once to SSH, 39% had at least one emergency department admission, 17% were admitted to an intensive care unit, 15% received at least one chemotherapy session (<60 years: 27%), and 5% received oral chemotherapy. Eighty-eight percent of the 60% of individuals who received hospital palliative care (HPC) vs 75% of those without HPC were admitted to SSH at least once during the last month. Cancer was the main cause of death for 84% (SSH: 85%, home: 77%) and corresponded to CRC for 64% of them. The mean annual expenditure per person during the last year of life was €43 398 (SSH: €48 804). This study suggests a relatively high level of HPC use during the year before death for people with CRC in France. High rates of emergency department, intensive care, and chemotherapy use were observed during the last month of life. However, management is very largely SSH-based with a small proportion of deaths at home.

Burden of drug use for gastrointestinal symptoms and functional gastrointestinal disorders in France: a national study using reimbursement data for 57 million inhabitants.

BACKGROUND: Gastrointestinal therapeutic drugs (GTDs) are extensively prescribed. The aim of this study was to investigate the characteristics of GTD use in a large population: the French general health scheme beneficiaries (87% of the 66 million inhabitants) in 2016. METHODS: The national health data system was used to identify individual characteristics, diseases and GTD classes reimbursed, together with the costs, using anatomical therapeutic chemical class. RESULTS: Among the 57.5 million individuals included, 45% received at least one reimbursement among the 130 million prescriptions reimbursed (90% prescribed by a general practitioner): proton-pump inhibitors (PPI; A02BC: 24%), drugs for functional gastrointestinal disorders (A03: 20%), drugs for constipation (A06: 10%), antidiarrheals, intestinal anti-inflammatory/anti-infective agents (A07: 10%), antiemetics and antinauseants (A04: 7%), other drugs for acid-related disorders (A02X: 6%), other drugs for peptic ulcer and gastro-oesophageal reflux disease (A02BX: 4.5%), antacids (A02A: 1.5%). The overall cost of reimbursed GTDs was €707 million and the mean cost per user was €28. Marked variations were observed according to age, sex, and disease. The rates of at least one reimbursement among infants were A07: 28%, A03: 17%, A02BX: 9%, A02X: 7%, A02BC: 6% and A06: 5%. Women more frequently received a reimbursement than men for each GTD class. Reimbursement rates also varied according to health status (end-stage renal disease A02BC: 66%, pregnancy A03: 53%, A04: 11%), treatments (people with at least six reimbursements for nonsteroidal anti-inflammatory drugs in 2016 A02BC: 62%). Chronic GTD use (>10 reimbursements/year) was observed in 19% of people with at least one A02BC reimbursement, A02BX: 11%, A03: 7%, A04: 2%, A06: 17% and A07: 3%. CONCLUSIONS: This study demonstrates extensive and chronic use of GTD in France, raising the question of their relevance according to current guidelines. They must be disseminated to general practitioners, who are the main prescribers of these drugs.

Healthcare use by 30,000 patients with irritable bowel syndrome (IBS) in France: a 5-year retrospective and one-year prospective national observational study.

BACKGROUND: Irritable bowel syndrome (IBS) can be responsible for alteration in quality of life and economic burden. The aim of this study was to evaluate healthcare use related to this disorder in France. METHODS: The French health data system was used to select adults covered by the general health scheme (87% of population) through their first IBS hospitalization in 2015. We studied the healthcare refunded during the previous 5 years, 1 year before and after hospitalization. RESULTS: Among 43.7 million adults who used refunded healthcare in 2015, 29,509 patients were identified (0.07, 33% males, 67% females, mean age 52 years, 30% admitted through emergency room). During their hospitalization, 33% had upper endoscopy and 64% colonoscopy. Over the five previous years, 3% had at least one hospitalization with an IBS diagnosis, 58% had abdominal ultrasonography, 27% CT scan, 21% upper endoscopy, 13% colonoscopy and 83% a gastroenterologist visit. The year before, these rates were respectively: 0, 36, 16, 6, 4 and 78%. Some of those rates decreased the year after the hospitalization with respectively: 1, 27, 13, 5, 4 and 19%. The year before, 65% had at least one CRP dosage (13% three or more), 58% a TSH dosage (7%) and 8% a test for coeliac diseases (1%) and the year after: 44% (8%), 43% (5%) and 3% (0.3%). At least one refund of a drug used to treat IBS was found for 85% of patients 5 years before, 65% one year before and 51% one year after. CONCLUSION: This first study using French health data system for healthcare consumption assessment in IBS points out the repetition of outpatient visits, examinations and in particular radiological examinations, without a strong decrease after hospitalization for IBS and gastroenterologist visit.

Patient characteristics and treatments one year after diagnosis of renal cancer in 2015 according to the presence or absence of metastasis and a history of another tumour: A national observational study.

INTRODUCTION: This study describes the characteristics, management and outcome of patients one year after a diagnosis of renal cancer, according to the presence of a history of another tumour and metastases at diagnosis or during the first year. METHODS: Based on information from the national health data system (SNDS), 10,989 general scheme beneficiaries (>15 years) with a first hospital stay in 2015 for renal cancer were divided into groups according to the presence of a history of another tumour or metastases. RESULTS: In this cohort of 10,989 people (75 years and older: 30%, men: 65%), 12% had a history of another tumour diagnosed during the two years before and 22% presented one or more metastases at the time of the index hospitalisation or during the following year. Overall, nephrectomy was performed in 56% of cases (partial nephrectomy in 29% of cases), in 63% and 36% of cases without metastases and in 68% and 40% of cases without metastases and with no history of another tumour. Overall, 2% of patients received at least one monoclonal antibody and 15% received a protein kinase inhibitor. These drugs were used in 6% and 53% of cases, respectively, in the presence of metastases and in 7% and 31% of cases, respectively, in the presence of metastases and a history of another tumour. CONCLUSION: This study highlights the high rate of a history of another tumour and adaptation of treatment according to a history of cancer and the presence of metastases.

Impact of type 2 diabetes on health expenditure: estimation based on individual administrative data.

Only limited data are available in France on the incidence and health expenditure of type 2 diabetes. The objective of this study, based on national health insurance administrative database, is to describe the expenditure reimbursed to patients newly treated for type 2 diabetes and the proportion of expenditure attributable to diabetes. The study is conducted over a 6-year period from 2008, the year of incidence of treated diabetes, to 2014. Type 2 diabetic patients aged 45 years and older are identified on the basis of their drug consumption. To estimate expenditure attributable to diabetes, a matched control group is selected among more than 13 million beneficiaries over 44 years old not taking antidiabetic treatment. The expenditure attributable to diabetes is estimated by two methods: simple comparison of reimbursed health expenditure between both groups, and a difference-in-differences method including control variables. The cohort of incident type 2 diabetic patients comprises 170,013 patients in 2008. Mean global reimbursed expenditure is €4700 per patient in 2008 and €5500 in 2015. Expenditure attributable to diabetes, estimated by direct comparison with controls, is €1500 in the first year. We, thus, observe a decrease in the following year due to decreased hospitalisations, and then expenditure increase by an average of 7% per year to reach €1900 in the eighth year after the initiation of treatment.

Two morbidity indices developed in a nationwide population permitted performant outcome-specific severity adjustment.

OBJECTIVE: The objective of the study was to develop and validate two outcome-specific morbidity indices in a population-based setting: the Mortality-Related Morbidity Index (MRMI) predictive of all-cause mortality and the Expenditure-Related Morbidity Index (ERMI) predictive of health care expenditure. STUDY DESIGN AND SETTING: A cohort including all beneficiaries of the main French health insurance scheme aged 65 years or older on December 31, 2013 (N = 7,672,111), was randomly split into a development population for index elaboration and a validation population for predictive performance assessment. Age, gender, and selected lists of conditions identified through standard algorithms available in the French health insurance database (SNDS) were used as predictors for 2-year mortality and 2-year health care expenditure in separate models. Overall performance and calibration of the MRMI and ERMI were measured and compared to various versions of the Charlson Comorbidity Index (CCI). RESULTS: The MRMI included 16 conditions, was more discriminant than the age-adjusted CCI (c-statistic: 0.825 [95% confidence interval: 0.824-0.826] vs. 0.800 [0.799-0.801]), and better calibrated. The ERMI included 19 conditions, explained more variance than the cost-adapted CCI (21.8% vs. 13.0%), and was better calibrated. CONCLUSION: The proposed MRMI and ERMI indices are performant tools to account for health-state severity according to outcomes of interest.

The economic burden of diabetes to French national health insurance: a new cost-of-illness method based on a combined medicalized and incremental approach.

A better understanding of the economic burden of diabetes constitutes a major public health challenge in order to design new ways to curb diabetes health care expenditure. The aim of this study was to develop a new cost-of-illness method in order to assess the specific and nonspecific costs of diabetes from a public payer perspective. Using medical and administrative data from the major French national health insurance system covering about 59 million individuals in 2012, we identified people with diabetes and then estimated the economic burden of diabetes. Various methods were used: (a) global cost of patients with diabetes, (b) cost of treatment directly related to diabetes (i.e., 'medicalized approach'), (c) incremental regression-based approach, (d) incremental matched-control approach, and (e) a novel combination of the 'medicalized approach' and the 'incremental matched-control' approach. We identified 3 million individuals with diabetes (5% of the population). The total expenditure of this population amounted to €19 billion, representing 15% of total expenditure reimbursed to the entire population. Of the total expenditure, €10 billion (52%) was considered to be attributable to diabetes care: €2.3 billion (23% of €10 billion) was directly attributable, and €7.7 billion was attributable to additional reimbursed expenditure indirectly related to diabetes (77%). Inpatient care represented the major part of the expenditure attributable to diabetes care (22%) together with drugs (20%) and medical auxiliaries (15%). Antidiabetic drugs represented an expenditure of about €1.1 billion, accounting for 49% of all diabetes-specific expenditure. This study shows the economic impact of the assumption concerning definition of costs on evaluation of the economic burden of diabetes. The proposed new cost-of-illness method provides specific insight for policy-makers to enhance diabetes management and assess the opportunity costs of diabetes complications' management programs.

End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported.

Although end-of-life medical spending is often viewed as a major component of aggregate medical expenditure, accurate measures of this type of medical spending are scarce. We used detailed health care data for the period 2009-11 from Denmark, England, France, Germany, Japan, the Netherlands, Taiwan, the United States, and the Canadian province of Quebec to measure the composition and magnitude of medical spending in the three years before death. In all nine countries, medical spending at the end of life was high relative to spending at other ages. Spending during the last twelve months of life made up a modest share of aggregate spending, ranging from 8.5 percent in the United States to 11.2 percent in Taiwan, but spending in the last three calendar years of life reached 24.5 percent in Taiwan. This suggests that high aggregate medical spending is due not to last-ditch efforts to save lives but to spending on people with chronic conditions, which are associated with shorter life expectancies.